Annexure VI

Inward Number___________________ Plan Name. LIC’s Cancer Cover Plan

Proposal Number__________________ Plan No. ________________________

Latest Photograph
Date of receipt of Proposal _________ Pol. Term /PPT _____________________

Policy Number_______________ Premium Mode _____________________

Date of policy issuance:____________________ Installment Premium ________________

URN: HPF-1 PROPOSAL FORM FOR LIC’s CANCER COVER

Branch Office…………………………………………. Divisional Office…………………………………. R/U/F/S……………………………..

Agent’s Name ………………………………………… Code No.…………….. Authorisation No……………… Authorisation expiry date………………
Development Officer’s name................................................. Development Officer’s Code………………………
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1. PROPOSER DETAILS:
Full Name (Max 40 Char)
Father’s Name
Nationality If NRI, Country of
Residence
Place of Birth Objective of Insurance
Age Proof (Nature of Age Proof) Date of Birth Age (Lbd) Sex Male/Female
Address for communication

City/Town District
State PIN Code
Permanent residential Address

City/Town District
State PIN Code
Telephone STD code …………… Phone No.…………………….. Mobile (+91)
E-Mail id
Residence Proof
Qualification Annual Income & Rs.
Source of Income
Occupation Income Proof
Name of Employer Nature of Duty

PAN Number- Aadhar No.- Passport No.-

Are you (Proposer) registered under the GST Act: Yes / No
If Yes, Provide GSTIN ___________________.

Term Mode of Sum Assured Benefit Options (Choose one of the following options)
Premium
Payment
Option I- Level Sum Insured: Option II- Increasing Sum Insured:

2. PROPOSAL DEPOSIT DETAILS: Cash Cheque

BOC No. Date Amount Rs.

ONLINE proposal (access ID)

3. NOMINATION DETAILS:

Nominee’s Full Name

Age Relationship
Appointee’s Name Appointee’s
(if Nominee is minor) Signature
Appointee’s address
 4. BANK DETAILS: (Please enclose a cancelled cheque)
IFSC (11 digits) MICR Number (As given on the
cheque leaf)
Account Number (As given on the Account Type (Savings/Current)
cheque leaf)
Bank Name Bank Branch

5. Has any of your new proposal/ application for revival/reinstatement for medical, health related insurance or riders or critical illness been
refused, withdrawn, declined, postponed or offered with restricted benefits or with an increased (extra) premium with LIC or any other insurer in
India or abroad?
If Yes, please provide details in the table below YES| NO

Name of the Policy No Plan/ CI Rider Sum Assured Date of Terms of Reason for substandard
Insurer & Term commencement Acceptance/D Terms/
ecline/Postpo Decline/Postpone/Reject
ne/Reject

6. Are you a politically exposed person OR are you a family member or close relative of politically exposed person? [As per RBI guidelines PEPs are
the individuals who are or have been entrusted with prominent public functions in a foreign country] { Yes / No }

7. HEALTH DETAILS AND MEDICAL INFORMATION

DETAILS Remarks
i. Do you consume or have ever consumed Narcotics?  Yes  No

ii. Do you smoke cigarettes/ bidis or consume tobacco in any form?  Yes  No

a) If yes, please specify the number of cigarettes/ bidis smoked per day _________________

b) Have you consumed any form of chewable tobacco in the last 12 months?  Yes  No

iii. Have you ever been advised to quit alcohol consumption for health reasons OR diagnosed with any liver
abnormalities due to alcohol consumption?  Yes  No
iv. Has either of your parents and /or brother or sister suffered/suffering from, or died due to cancer
before the age of 60 years? If YES give following details;
 Yes  No
What type of Cancer _____________________ Relation with the person contracting Cancer
_________________________________

Age at diagnosis ____________________________ Age at Death (If any)

____________________________________________________

v. Health Details- Height (in Cms) ________________; Weight (in Kgs) _____________________

 Yes  No
In the past six months has your weight reduced by 5 kgs or more other than due to diet control
exercise or post pregnancy?
vi. Provide details of Total Existing Critical Illness cover/Cancer Cover with all insurance companies including LIC:

Co. name P&T TYPE - SA DOC Accepted at Inforce /

CI/Cancer lapsed
cover

Does your Critical Illness cover/Cancer Cover with all insurance companies including LIC exceed
 Yes  No
INR 5,000,000/- including current application?
 vii. Have you ever received consultation, medical advice, been investigated, undergone surgery or
been treated or have noticed signs and symptoms for following:  Yes  No

a) Cancer, lump, swelling, growth, nodes, cyst, tumour, non-healing ulcer and increase in  Yes  No
size of number of moles anywhere in your body?
b) Any persistent loss of blood or unusual discharge from any part of the body?  Yes  No
c) Persistent – fever / headache / cough, difficulty in swallowing, hoarseness of voice (all
of the previous symptoms for more than 21 days), visual disturbances, seizures, loss of  Yes  No
consciousness, blood disorders, abnormal blood cell count? If yes, please provide
details.

__________________________________________________________________

d) For female Lives Only:

Any disease or disorder of the cervix, uterus ovaries or vagina, abnormal bleeding OR any disease or disorder
of the Breast(s) such as breast lump/cyst, fibrocystic disease, nipple changes or discharge? If Yes, please  Yes  No
provide details

_________________________________________________________________________________

viii. Have you or your spouse ever been tested positive for HIV / AIDS, hepatitis B or C or any  Yes  No
sexually transmitted disease?

ix. Other than as a part of routine / executive / pre-employment check-up, Have you been advised
to undergo any investigations in last 6 months like ultrasound (USG), body scan, MRI, CT
scan, cytology, pap smear, mammogram, colonoscopy, biopsy, blood tests, cancer / tumor  Yes  No
markers? If yes, please provide details.
_____________________________________________________________________________

8. QUESTIONS APPLICABLE FOR FEMALE LIVES : i) Husband’s Full Name: _________________________________________

ii) Husband’s existing health insurance cover: SA amount ____________ Ins. Co. name: _____________ Nature of cover of (CIR, Health Ins, Cancer
Cover): ____________________________

IMPORTANT: If answer to any of the above question is “Yes”, please provide details (precise diagnosis, past and current treatment, current status,
treatment plan for future) in a separate sheet of paper and submit copies of hospital/consultation/investigation reports available with you).

DECLARATION BY THE PROPOSER

I _____________________ declare that I am fully aware of the statements / contents etc. given by me in this proposal form and confirm that they are true and
complete in all respects to the best of my knowledge and that I have not withheld any information and I do hereby agree and declare that the same shall form the
basis of the contract and that if any untrue averment be contained therein the said contract shall be dealt with as per provisions of Section 45 of the Insurance
Act, 1938 as amended from time to time.

I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the
Corporation and that the policy will come into force only after full payment of the premium chargeable.

I further agree that any change / addition / deletion / alteration related to my health, occupation, or any other adverse circumstance (including dropping,
deferment, acceptance at terms other than as proposed of any proposal/ revival of policy made to the Corporation or any other insurance company) after the
submission of this proposal to the Corporation shall be conveyed before the issuance of the First Premium Receipt/ communication of acceptance of risk. Any
omission on my part to do so shall render this assurance invalid. I authorize the Corporation to make any enquiry to anyone concerning our health.

I declare that I consent to the Corporation seeking medical information from any doctor or hospital who/which at any time has attended me or from any past or
present employer concerning anything which affects the physical or mental health of mine and seeking information from any insurer to whom an application for
insurance on my life has been made for the purpose of underwriting the proposal and/or claim settlement.

I authorize the Corporation to share information pertaining to my proposal including the medical records of mine for the sole purpose of underwriting the
proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

In consultation with the agent / intermediary, I understood the plan features and have taken a personal and independent decision in an informed manner to go
for the Plan. I understand that the ‘application money’ deposited by me is a token consideration under this proposal for insurance and that the policy will come
into force only after full payment of the premium chargeable.
I have read and understood:
 SECTION 45 OF THE INSURANCE ACT,1938 AS AMENDED BY INSURANCE LAWS(AMENDMENT )ACT,2015
(1) No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy, i.e., from the date of issuance of the policy or
the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later.
(2)A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the
policy or the date of the rider to the policy, whichever is later, on the ground of fraud :
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and the materials on which such
decision is based.
Explanation I - For the purpose of this sub section, the expression “fraud” means any of the following acts committed by the insured or by his agent, with the intent to deceive the insurer or
to induce the insurer to issue a life insurance policy :
(a) The suggestion, as a fact of that which is not true and which the insured does not believe to be true;
(b) The active concealment of a fact by the insured having knowledge or belief of the fact ;
(c) Any other act fitted to deceive ; and
(d) Any such act or omission as the law specially declares to be fraudulent.
Explanation II – Mere silence as to facts likely to affect the assessment of the risk by the insurer is not fraud, unless the circumstances of the case are such that regard being had to them, it is
the duty of the insured or his agent, keeping silence to speak, or unless his silence is, in itself, equivalent to speak.
(3) Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the ground of fraud if the insured can prove that the mis-statement of or
suppression of a material fact was true to the best of his knowledge and belief or that there was no deliberate intension to suppress the fact or that such mis-statement of or suppression of a
material fact are within the knowledge of the insurer:
Provided that in case of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.
Explanation: A person who solicits and negotiates a contract of insurance shall be deemed for the purpose of the formation of the contract, to be agent of the insurer.
(4) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the
policy or the date of the rider to the policy, whichever is later, on the ground that any statement of or suppression of a fact material to the expectancy of the life of the insured was incorrectly
made in the proposal or other document on the basis of which the policy was issued or revived or rider issued:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and materials on which such
decision to repudiate the policy of life insurance is based:
Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and not on ground of fraud, the premiums collected on the policy till
the date of repudiation shall be paid to the insured or the legal representatives or nominees or assignees of the insured within a period of ninety days from the date of such repudiation.
Explanation – For the purposes of this sub-section, the mis-statement of or suppression of fact shall not be considered material unless it has a direct bearing on the risk undertaken by the
insurer, the onus is on the insurer to show that had the insurer been aware of the said fact no life insurance policy would have been issued to the insured.
(5) Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the
terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.’

SECTION 41 OF THE INSURANCE ACT,1938 AS AMENDED BY INSURANCE LAWS(AMENDMENT )ACT,2015

1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating
to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing
or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.

Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of
a rebate of premium within the meaning of this sub-section if at the time of such acceptance the Insurance agent satisfies the prescribed conditions establishing that he is a bonafide
Insurance Agent employed by the insurer.

2) Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.

Dated at …………………………………………………………….. On the……………………………… Day of …………………………20

Witness: ( Signature of the Proposer)

(Signature, Name & Address)
.

In case form is filled up / signed in a language different from that of the Proposal Form:

Declaration by the person filling in the form: “I hereby declare that I have fully explained the above questions to the proposer in _________ language and I have
truthfully recorded the answers given by the proposer.”

Name &Address of the declarant ______________________ Signature of the declarant:__________________________

Declaration by the Proposer

“I certify that the contents of the form and documents have been fully explained to me by Mr/ Ms:___________________ and I have understood
the significance of the proposed contract”.

Signature of the Proposer:_________

Addendum to Proposal Form for LIC’s e-services

(Fields marked with asterisk (*) are compulsory)

(a) Do you wish to avail LIC’s e-services for your

Policy through the Customer Portal of L.I.C. of India? YES / NO

(b) Are you already registered with customer portal of LIC of India? YES / NO

(c) If yes, please provide Policy Number of one of

the policies enrolled on the customer portal : | | | | | | | |

(d) Your e-mail id for future correspondence (*)

(e) Your Mobile Number (*) : 9|1| | | | | | | | | |

 (f) PAN Number: | | | | | | | | |

(g) Passport Number: | | | | | | | | | | |

(h) UID (Aadhaar) Number: | | | | | | | | | | |

(It is mandatory to provide either PAN No, Passport No or UID No. for availing LIC’s e services)

Date : ___________ _____________________

Signature of the Proposer

Place : ___________ Name of Proposer : ___________________

AGENT’S CONFIDENTIAL REPORT/MORAL HAZARD REPORT

Agent’s Name & Code Club Authorisation Authorisation Development Branch

Membership No. expiry date Officer Code Code

Name of Life Proposed Age Occupation

Nature of duties

1. (a) Acquaintance with the proposer (No. of Years):

(b) Relationship with the proposer :

(c) Educational qualification of the Life Proposed:

2. Annual Income: Rs……………………………………………………….. Income Source……………………………………………………………………..

Proof of Income…………………………………………………………………. …………… Verified: …Yes/No ……………………PAN………………….
3. Physical Measurements and Identification Marks of the Proposer and other Members (beneficiaries) to be insured under the proposal.

Proposer Name Height Weight Abdomen Chest Identification Marks

(cms) (kgs) (cms) (exp/ins)
cms
1.
2.
4. Are you aware whether LP or any of LP’s first degree relatives (which includes the parents, full siblings or children) is/are suffering from Cancer?  Yes 
No . If YES, give complete details on a separate paper.
5. Declaration by the Agent

I do hereby declare that I have personally seen the proposer and I do hereby confirm that there is no physical deformity / impaired sight / hearing problem /
mental retardation or any other diseases including cancer and am personally satisfied about his / her financial condition. I also declare that I have explained fully
the terms and conditions of the plan to the proposer. I further inform that no proposal / revival has been deferred / declined / dropped / accepted with extra
premium. I am fully aware that the policy shall be issued based on my above declaration that if any information given above is incorrect, it would attract penalty
under Regulation 16 and other provisions of Life Insurance corporation of India (Agents) Regulations, 2017, besides the other provisions of law applicable.

Dated at on the day of 20

Agent’s Address & Phone No. _____________________________________________________ ( Signature of the Agent )

I am fully aware and endorse the above contents; I recommend the proposal for acceptance.

Development Officer / CLIA Assistant Branch Manager (Sales)/Chief/Sr./Branch Manager.